Lay/Pre-Certification Program (HS/GED Required For Enrollment)
NCCA Certification Only Program (HS/GED Required For Enrollment)
NCCA License Only Program (Master's Degree Required For Enrollment)
NCCA License + AA/BA/MA Program (HS/GED Required For Enrollment)
NCCA NCCA License + BA/MA Program (HS/GED Required For Enrollment)
NCCA License + MA Degree Program (Bachelor's Degree Required For Enrollment)
NCCA License + Doctorate (PhD) Degree Program (Master's Degree Required For Enrollment)
NCCA + 2d Doctorate Degree Program (Doctorate Degree Required For Enrollment)

PERSONAL INFORMATION: (Fill In All Areas)

Your EMail Address:
Your Name:
Street Address: City, State, Zip Code:
Your Age ?: (Month, Day, Year) Gender (Male/Female):
Contact Telephone Number:

PLEASE COMPLETE THE FOLLOWING (As Applicable)

I Am a Born-Again Believer and Have Been A Christian For: Years

I Graduated From High School In 19

Do You Have a Associates Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:

Do You Have a Bachelor's Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:

Do You Have a Master's Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:

Do You Have a Doctorate Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:

Have You Ever Been Convicted Of A Felony? (Yes/No)
If Yes, please explain in detail

Are You Currently A Commissioned, Licensed, or Ordained Minister? (Yes/No)
If Yes, What Year Were You Credentialed?
Denomination?

RESPOND TO THE FOLLOWING: (Check All That Apply)
I am interested in obtaining ministerial credentials
I desire to develop an outreach ministry of counseling in my church or in my community

WE WANT TO GET TO KNOW YOU A LITTLE BETTER. WITHIN THE SPACES PROVIDED, BRIEFLY RESPOND TO THE FOLLOWING:

Briefly Tell Us About Your Christian Walk, Church/Ministry Involvement, and Personal Testimony:

PLEASE TELL US HOW YOU FOUND OUR PROGRAMS (Check Only One)

Previously Completed Courses Through RMCM or NCCA TV Ad Radio Ad Christian Magazine Internet ChristianityToday.Com
Referred By: Other. Describe:

Thank you for filling out our evaluation/inquiry form. The information you provide will be very helpful in identifying a degree/credential program of study that will best fit your needs. Once you have completed and submitted this inquiry form, we will make every effort to contact you BY PHONE or EMAIL within 2 business days. Many times, we initiate contact and get answering machines. We will leave a message notifying you that we called, and will ask you to call us back on our toll-free number. Altogether, we make 2 or 3 attempts to contact you by phone and email. Please help us, by being promptly available to discuss your program interest with us, or give us a courtesy call if we leave a message to follow up. Because of the nature of various internet service providers and spam filters, please take a moment and add mdesigns@dmrtc.net and counselor@rmcm.org to your approved/accepted email list.